1972650109 NPI number — LISA J SIDDALL FNP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972650109 NPI number — LISA J SIDDALL FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIDDALL
Provider First Name:
LISA
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972650109
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21475 RIDGETOP CIR
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
STERLING
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20166-6580
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-444-5000
Provider Business Mailing Address Fax Number:
703-444-4999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21475 RIDGETOP CIR
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
STERLING
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20166-6580
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-444-5000
Provider Business Practice Location Address Fax Number:
703-444-4999
Provider Enumeration Date:
01/03/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  R174726 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 0024168490 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)